571976 research-article2015
HPQ0010.1177/1359105315571976Journal of Health PsychologyHouston et al.
Article
Another look at depressive symptoms and antiretroviral therapy adherence: The role of treatment self-efficacy
Journal of Health Psychology 2016, Vol. 21(10) 2138–2147 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359105315571976 hpq.sagepub.com
Eric Houston1, Cassandra Mikrut1, Arryn Guy1, Adam W Fominaya1, Alexander K Tatum2, Jeong H Kim1 and Annette Brown3
Abstract Depression has been strongly associated with poor HIV treatment adherence, but little research has explored how individuals manage to follow their regimens despite symptoms of major depression. Using a sample of antiretroviral therapy patients with clinically significant depressive symptoms (n = 84), we examined whether patients with optimal adherence differed from those with suboptimal adherence in terms of the types of depressive symptoms experienced and treatment self-efficacy. There were no significant differences between participants with regard to types of depressive symptoms. Findings indicate that patients with high treatment self-efficacy were more likely to report optimal levels of adherence than patients with low self-efficacy.
Keywords antiretroviral adherence, depressive symptoms, health disparities, HIV
Introduction Depressive symptoms are pervasive among people living with HIV (Orlando et al., 2002; Safren et al., 2001; Wagner et al., 2011). Research consistently shows a higher prevalence of depressive symptoms and mood disorders among individuals who are HIV seropositive than among individuals in the general population. A nationally representative probability sample of individuals under care for HIV found that 37 percent met screening criteria for major depressive disorder, nearly five times greater than rates for a general population sample (Bing et al., 2001). In addition, studies indicate that rates of dysthymic disorder are
nearly two times higher among persons living with HIV than those without the virus (Ciesla and Roberts, 2001). A large body of research indicates that depressive symptoms among patients undergoing 1Illinois
Institute of Technology, USA University Chicago, USA 3The Chicago School of Professional Psychology, USA 2Loyola
Corresponding author: Eric Houston, Department of Psychology, Illinois Institute of Technology, 3105 S. Dearborn St., Chicago, IL 60616, USA. Email: [email protected]
Houston et al. antiretroviral therapy are strongly associated with poor adherence, disengagement from care, and unfavorable treatment outcomes (Gonzalez et al., 2011; Sherr et al., 2011; Springer et al., 2012; Wagner et al., 2011). Adherence rates of 95 percent or greater are widely regarded as optimal to achieve virologic suppression and derive immunological benefits, but more than half of antiretroviral therapy patients are unable to sustain these levels (De Bruin et al., 2010). Due to the negative impact of depressive symptoms on antiretroviral therapy adherence, many interventions seek to improve adherence by alleviating depressive symptoms (Antoni et al., 2006; Carrico et al., 2005; Newcomb et al., 2014; Raja et al., 2007; Safren et al., 2009; Simoni et al., 2013). However, findings from these studies have been mixed (Sherr et al., 2011), suggesting that current interventions do not adequately address the problem of poor medication adherence among patients with depression. Despite the strong association between depressive symptoms and poor adherence, there is evidence from both research and clinical practice that some individuals with depression are able to attain adherence at optimal levels (Ammassari et al., 2004; Bottonari et al., 2012; Jean-Baptiste, 2008; Maeda et al., 2013; Wendorf and Mosack, 2013). Relatively few studies, however, have examined the internal resources and personal strengths that antiretroviral therapy patients may utilize when faced with persistent depressive disorder, recurrent episodes of major depression, or an escalation of existing symptoms. In this secondary analysis of data from two separate studies of adherence behavior among patients undergoing antiretroviral therapy (Houston et al., 2012; Houston and McKirnan, 2010), we compared patients with clinically significant depressive symptoms who had achieved optimal levels of adherence to their counterparts with suboptimal adherence. The sample consisted primarily of individuals with low socioeconomic status. The majority of the sample also identified as African-American and female. Psychosocial stressors faced by members of these groups may increase their vulnerability for
2139 depression, adding to the considerable challenges posed by consistent adherence to an antiretroviral regimen (Cargill et al., 2004; Schilder et al., 2001; Siegel et al., 2000; Thrasher et al., 2008). Given continued evidence of disparities in HIV treatment outcomes experienced by racial/ethnic minorities and individuals with low socioeconomic status (Cargill, 2013; Millett, 2013; Steele et al., 2007), research focusing on how adherence goals may be reached despite adverse conditions is particularly critical. Previous studies have consistently associated optimal adherence with treatment self-efficacy (Ammassari et al., 2004; Dima et al., 2013; Marc et al., 2007; Mills et al., 2006; Nokes et al., 2012; Reynolds et al., 2004; Wilson et al., 2004). Self-efficacy, the degree to which individuals feel confident in their ability to complete tasks and achieve goal outcomes, is a key component of social cognitive theory (SCT; Bandura, 1986). SCT, a theoretical framework that emphasizes the reciprocal relationship between cognitive, environmental, and behavioral factors, has been used in several studies to explain antiretroviral adherence outcomes (e.g. Brown et al., 2013; Watt et al., 2009). Suboptimal adherence due to inadequate self-efficacy could lead to treatment failure. In resource-limited settings, patients who are unable to persist with treatment face fewer alternatives for treatment, making selfefficacy a particularly critical factor to consider in patient outcomes (Muñoz et al., 2010; Polisset et al., 2009). There is a paucity of research focusing on the factors that aid patients who are depressed in adhering to their antiretroviral therapy regimens. This study represents one of the first quantitative empirical investigations that focuses on how self-efficacy may affect adherence behavior among these patients. Research indicates that depressive symptoms negatively affect self-efficacy, leading to poor adherence behaviors (Maciejewski et al., 2000; Sánchez et al., 2011). What remains unclear, however, is whether some patients who are depressed are able to attain self-efficacy at sufficient levels to achieve optimal adherence. In the current study,
2140 we hypothesized that adherence would be positively associated with self-efficacy. In addition, we hypothesized that patients with high levels of self-efficacy would be more likely to experience optimal adherence despite the persistent presence of elevated depressive symptoms. By examining antiretroviral therapy patients with similar levels of depressive symptoms, we sought to more unambiguously assess the extent to which a personal strength or internal resource such as self-efficacy could account for variations in adherence.
Method Participants Participants (n = 84) were drawn from two prior cross-sectional studies. Study 1 (Houston and McKirnan, 2010) examined treatment perceptions and psychological factors associated with the use of antiretroviral therapy adherence reminder strategies among low-income urban women (n = 85). Study 2 (Houston et al., 2012) examined the relationship between treatmentrelated cognitions and motivation using a sample of men undergoing antiretroviral therapy (n = 39). For both studies, participants were assessed for depressive symptoms and treatment self-efficacy using the same measures. This study consists only of participants who were assessed as having clinically significant levels of depressive symptoms based on the Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977). Thus, the combined sample includes 65 participants from Study 1 and 19 participants from Study 2 who met these threshold levels of depressive symptoms. There were no significant differences between the two individual samples in terms of demographic or clinical characteristics (i.e. ethnicity/race, age, income, adherence, time since diagnosis, and depressive symptoms based on the CES-D); however, men (Study 1 participants) were more likely than women (Study 2 participants) to report having a high school diploma or more years of schooling (73.7% vs 45.3%), χ2 (1, n = 84) = 4.723, p
HPQ0010.1177/1359105315571976Journal of Health PsychologyHouston et al.
Article
Another look at depressive symptoms and antiretroviral therapy adherence: The role of treatment self-efficacy
Journal of Health Psychology 2016, Vol. 21(10) 2138–2147 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359105315571976 hpq.sagepub.com
Eric Houston1, Cassandra Mikrut1, Arryn Guy1, Adam W Fominaya1, Alexander K Tatum2, Jeong H Kim1 and Annette Brown3
Abstract Depression has been strongly associated with poor HIV treatment adherence, but little research has explored how individuals manage to follow their regimens despite symptoms of major depression. Using a sample of antiretroviral therapy patients with clinically significant depressive symptoms (n = 84), we examined whether patients with optimal adherence differed from those with suboptimal adherence in terms of the types of depressive symptoms experienced and treatment self-efficacy. There were no significant differences between participants with regard to types of depressive symptoms. Findings indicate that patients with high treatment self-efficacy were more likely to report optimal levels of adherence than patients with low self-efficacy.
Keywords antiretroviral adherence, depressive symptoms, health disparities, HIV
Introduction Depressive symptoms are pervasive among people living with HIV (Orlando et al., 2002; Safren et al., 2001; Wagner et al., 2011). Research consistently shows a higher prevalence of depressive symptoms and mood disorders among individuals who are HIV seropositive than among individuals in the general population. A nationally representative probability sample of individuals under care for HIV found that 37 percent met screening criteria for major depressive disorder, nearly five times greater than rates for a general population sample (Bing et al., 2001). In addition, studies indicate that rates of dysthymic disorder are
nearly two times higher among persons living with HIV than those without the virus (Ciesla and Roberts, 2001). A large body of research indicates that depressive symptoms among patients undergoing 1Illinois
Institute of Technology, USA University Chicago, USA 3The Chicago School of Professional Psychology, USA 2Loyola
Corresponding author: Eric Houston, Department of Psychology, Illinois Institute of Technology, 3105 S. Dearborn St., Chicago, IL 60616, USA. Email: [email protected]
Houston et al. antiretroviral therapy are strongly associated with poor adherence, disengagement from care, and unfavorable treatment outcomes (Gonzalez et al., 2011; Sherr et al., 2011; Springer et al., 2012; Wagner et al., 2011). Adherence rates of 95 percent or greater are widely regarded as optimal to achieve virologic suppression and derive immunological benefits, but more than half of antiretroviral therapy patients are unable to sustain these levels (De Bruin et al., 2010). Due to the negative impact of depressive symptoms on antiretroviral therapy adherence, many interventions seek to improve adherence by alleviating depressive symptoms (Antoni et al., 2006; Carrico et al., 2005; Newcomb et al., 2014; Raja et al., 2007; Safren et al., 2009; Simoni et al., 2013). However, findings from these studies have been mixed (Sherr et al., 2011), suggesting that current interventions do not adequately address the problem of poor medication adherence among patients with depression. Despite the strong association between depressive symptoms and poor adherence, there is evidence from both research and clinical practice that some individuals with depression are able to attain adherence at optimal levels (Ammassari et al., 2004; Bottonari et al., 2012; Jean-Baptiste, 2008; Maeda et al., 2013; Wendorf and Mosack, 2013). Relatively few studies, however, have examined the internal resources and personal strengths that antiretroviral therapy patients may utilize when faced with persistent depressive disorder, recurrent episodes of major depression, or an escalation of existing symptoms. In this secondary analysis of data from two separate studies of adherence behavior among patients undergoing antiretroviral therapy (Houston et al., 2012; Houston and McKirnan, 2010), we compared patients with clinically significant depressive symptoms who had achieved optimal levels of adherence to their counterparts with suboptimal adherence. The sample consisted primarily of individuals with low socioeconomic status. The majority of the sample also identified as African-American and female. Psychosocial stressors faced by members of these groups may increase their vulnerability for
2139 depression, adding to the considerable challenges posed by consistent adherence to an antiretroviral regimen (Cargill et al., 2004; Schilder et al., 2001; Siegel et al., 2000; Thrasher et al., 2008). Given continued evidence of disparities in HIV treatment outcomes experienced by racial/ethnic minorities and individuals with low socioeconomic status (Cargill, 2013; Millett, 2013; Steele et al., 2007), research focusing on how adherence goals may be reached despite adverse conditions is particularly critical. Previous studies have consistently associated optimal adherence with treatment self-efficacy (Ammassari et al., 2004; Dima et al., 2013; Marc et al., 2007; Mills et al., 2006; Nokes et al., 2012; Reynolds et al., 2004; Wilson et al., 2004). Self-efficacy, the degree to which individuals feel confident in their ability to complete tasks and achieve goal outcomes, is a key component of social cognitive theory (SCT; Bandura, 1986). SCT, a theoretical framework that emphasizes the reciprocal relationship between cognitive, environmental, and behavioral factors, has been used in several studies to explain antiretroviral adherence outcomes (e.g. Brown et al., 2013; Watt et al., 2009). Suboptimal adherence due to inadequate self-efficacy could lead to treatment failure. In resource-limited settings, patients who are unable to persist with treatment face fewer alternatives for treatment, making selfefficacy a particularly critical factor to consider in patient outcomes (Muñoz et al., 2010; Polisset et al., 2009). There is a paucity of research focusing on the factors that aid patients who are depressed in adhering to their antiretroviral therapy regimens. This study represents one of the first quantitative empirical investigations that focuses on how self-efficacy may affect adherence behavior among these patients. Research indicates that depressive symptoms negatively affect self-efficacy, leading to poor adherence behaviors (Maciejewski et al., 2000; Sánchez et al., 2011). What remains unclear, however, is whether some patients who are depressed are able to attain self-efficacy at sufficient levels to achieve optimal adherence. In the current study,
2140 we hypothesized that adherence would be positively associated with self-efficacy. In addition, we hypothesized that patients with high levels of self-efficacy would be more likely to experience optimal adherence despite the persistent presence of elevated depressive symptoms. By examining antiretroviral therapy patients with similar levels of depressive symptoms, we sought to more unambiguously assess the extent to which a personal strength or internal resource such as self-efficacy could account for variations in adherence.
Method Participants Participants (n = 84) were drawn from two prior cross-sectional studies. Study 1 (Houston and McKirnan, 2010) examined treatment perceptions and psychological factors associated with the use of antiretroviral therapy adherence reminder strategies among low-income urban women (n = 85). Study 2 (Houston et al., 2012) examined the relationship between treatmentrelated cognitions and motivation using a sample of men undergoing antiretroviral therapy (n = 39). For both studies, participants were assessed for depressive symptoms and treatment self-efficacy using the same measures. This study consists only of participants who were assessed as having clinically significant levels of depressive symptoms based on the Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977). Thus, the combined sample includes 65 participants from Study 1 and 19 participants from Study 2 who met these threshold levels of depressive symptoms. There were no significant differences between the two individual samples in terms of demographic or clinical characteristics (i.e. ethnicity/race, age, income, adherence, time since diagnosis, and depressive symptoms based on the CES-D); however, men (Study 1 participants) were more likely than women (Study 2 participants) to report having a high school diploma or more years of schooling (73.7% vs 45.3%), χ2 (1, n = 84) = 4.723, p
